Reviews
them to the police. Suicide is viewed as a shameful act to
Beyond rates: the tragedy
of suicide in Pakistan
Murad M Khan as MRCPsych'
Martin Prince MD MRCPsych 2
'Department of Psychiatry,The Aga Khan University, Stadium
Road, PO Box 3500, Karachi-74800, Pakistan; 2Section of
Epidemiology, Institute of Psychiatry, De Crespigny Park, Denmark
Hill, London SE58AF, UK
Correspondence to: Dr Khan
E-mail: murad.khan@aku.edu
TROPICAL DOCTOR, 2003, 33, 67-69
Introduction
According to the World Health Organization (WHO),
between 500000 and 1.2 million people worldwide die
from suicide each year '. Acknowledging it as a global
tragedy, the WHO has noted with concern the significant
problem of underreporting, an upward trend in the
younger age groups and lack of comprehensive national
preventive strategy in many member countries.
While the subject is receiving considerable attention in
the West, it remains largely neglected in many countries of
the developing world. Pakistan's population of 140
million makes it the seventh most populous country in
the world. Of its population 97% are Muslims and 70%
live in rural areas. Karachi, situated in the south on the
shores of the Indian Ocean, is the largest city with a
population of more than 12 million. It is also the main
commercial and business centre. The national per capita
income is US$440, with a third of the population living
below the poverty line. With a Gross Domestic Product of
$63.6 billion, 31% is spent on defence, 2% on education
and less than I % on health/.
Suicide in Pakistan
Suicide is an under-studied and under-researched subject
in Pakistan. Basic epidemiological data, for example, on
national rates are not known. Like many developing
countries, Pakistan does not report suicide mortality
statistics to the WHO. A variety of social, legal and
religious factors complicate accurate reporting and data
collection.'.
The law in Pakistan (based on a tenet of Islam)
considers suicide and attempted suicide as a criminal
offence punishable with a jail term and (or a heavy
financial penalty. Every suspected case must be taken to
one of the government hospitals designated as a 'medico-
legal centre'. Only medico-legal centres are authorized to
receive forensic cases and the police conduct an inquiry
into the incident. Although prosecution is rare, harass-
ment and extortion of money from the victims' families is
not uncommon. Hence many are taken to private
hospitals which neither register the cases nor report
Tropical Doctor April 2003, 33
be concealed. Families are often ostracised and there may
be implications for marriage prospects for girls in the
family. For these reasons the actual incidence of suicide
and attempted suicide may be underestimated in Pakistan.
Suicide and Islam
The relationship between religious belief and suicide has
been well known since the first published governmental
social statistics appeared during the early and mid-
nineteenth century. Earlier studies compared suicide
rates between Catholics and Protestants. Both Masaryk"
and Morselli 5 noted that in a given district or area,
Catholics, who led a more ordered life through extensive
ritual and subordination to the Church hierarchy, had
lower suicide rates than Protestants. Durkheim'' also
concluded that religion had an independent role in
suppressing suicide, basing his contention not only of
the study of Catholics and Protestants but also of Jews.
Simpson and Conklin 7 compared suicide rates of Chris-
tian and Islamic countries using a 71-nation cross-
national analysis and confirmed Durkheim's earlier
hypothesis that traditional religion plays an important
role in the suppression of suicide.
Cross-cultural studies show that the rate of suicide is
low in Muslin countries. In a collection of essays edited by
Headley'', seven countries (i.e. Iran, Iraq, Egypt, Syria,
Jordan, Kuwait and Pakistan) with a majority Muslim
population were surveyed. They all showed a relatively
low rate of suicide compared to Western countries.
While suicide is a condemned act in most major
religions of the world Islam has declared it as an
unforgivable sin with perpetrators being condemned to
hell'', which may partly explain the low suicide rate in
Muslim countries, including Pakistan.
Suicide 'rates' in Pakistan
An early report based on police records showed 89
suicides (average 18(year) over a 5-year period (1959-
1963)10. A similar study repeated for the years 1974-78
showed 25 suicides (average 5(year)1l. A survey of all
suicides reported in a national newspaper over a 2-year
period (1996 and 1997) showed 306 suicides nationally
(average I53(year; for Karachi: 85(year)3. All four
provinces of the country (Sindh, Punjab, Balochistan
and North-West Frontier Province) and more than 35
cities were represented.
Over the last few years, reports and articles on suicide
have been appearing regularly in the lay press I2- 14 , with
several non-governmental and government organizations
reporting their figures. For example, a report by the
Human Rights Commission of Pakistan showed 2000
suicides nationally (average 250(month) in an eight-
month period (January-August 2000), compared to 2100
suicides (average 175(month) in 199912. Another report by
the Lawyers for Human Rights and Legal Aid reported
210 suicides nationally in the first 2 months of 2001[3. The
Sindh Police gave a figure of 233 suicides (average 33(
month) for a 7-month period (January to July 2000) for
67
 Reviews
the province of Sindh 14 . While these figures suggest an
apparent increase in suicides over previous years, they
could also reflect an earlier underrecording rather than a
real increase over time.
Suicide and economic factors
It has been speculated that deteriorating economic
conditions and increasing poverty are responsible for the
increase in rates 2,12 . Like many developing countries,
Pakistan finds itself caught in a vicious cycle of
dependency on international financial institutions and
an increasing spiral of debt. For example in the financial
year 1999-2000, while $673 millions were transferred into
Pakistan from major financial donors, $1206.6 millions
were transferred back against debt servicing and repay-
ment, giving a negative net amount of $538.8 millions 15.
The rigid enforcement of structural adjustments as the
sole mechanism for strengthening an already weakened
economy frequently leads to increases in social inequity:
this has a direct impact on the health sector, particularly
on the most vulnerable members of the population,
among them the unemployed and mentally ill.
Suicide and mental illness
While poverty and adverse economic conditions may have
impacted on suicide rates in recent years, the role of
interpersonal relationship problems and mental illness as
important contributory factors in attempted suicide and
suicides respectively, should not be overlooked'S". Popu-
lation-based prevalence studies from Pakistan give high
figures for depression. In one study, 44.4% (male 25.5%
and female 57.5%) of the cohort was found to be
depressed for more than a year 16 .
Similarly Mumford et aI.17.18 in two studies found the
prevalence of anxiety/depression in 66% and 60% of
women and 25% and 15-33% of men, respectively. The
authors concluded that the high prevalence of depression
in Pakistan might be because of the higher proportion of
the population experiencing social adversity.
It would appear that mental illness (especially depres-
sion) may be under-recognized and treated in Pakistan
and this could be another contribution to a pool from
which many suicides are drawn.
Taken as a whole, deteriorating economic conditions,
erosion of public confidence in national institutions
coupled with an unstable political system may have
created a sense of foreboding in the general population.
Against this background, traditional protective factors of
religion and cultural values may be losing their effect
leading to higher rates of distress and depression, leading
to suicide.
Women, marriage and suicide
Another area of consideration is that of marital status and
suicidal behaviour. Although gender difference in suicides
is similar to other countries with men outnumbering
women by two to three times, married women seem to be
particularly at risk', This finding is consistent with studies
of psychiatric morbidity in Pakistan, which also show
higher rates in married women compared to single women
or married menl''. It adds further weight to a growing
body of evidence that, instead of protecting against
psychiatric morbidity, marriage is a significant source of
stress for women in Pakistan.
68
Pakistani society is largely male dominated and women
have limited autonomy in areas such as education, career
or choice of marital partner '''. Divorce is so stigmatized it
is not a realistic option for women. Few women have jobs
giving them economic independence and invariably,
divorced women have to go back to their parents' home.
Under Islamic law, the father also has the right to custody
of children over 7 years of age. There is therefore
enormous pressure on women to continue in the marriage,
even an obviously unhappy one. Factors associated with
depression in Pakistani women include low self-esteem,
early marriage, hostile in-laws, and lack of a confiding
relationship with husband/". Recent evidence also sug-
gests a high incidence of domestic violence towards
women-l.
Beyond rates: the challenge of suicide prevention
Although it would be easy to dismiss the problem of
suicide in Pakistan as insignificant as rates of suicide, even
with the recent apparent increase, are probably quite low
compared to other countries it is important to look
beyond rates and numbers. As in any other country,
suicide is a serious public health problem in Pakistan but
with limited resources, poorly developed mental health
services and strong sociocultural sanctions against it, is
much more difficult to tackle.
There is compelling evidence indicating that adequate
prevention and treatment of some mental and behavioural
disorders can reduce suicide rates, whether such interven-
tions are directed towards individuals, families, schools or
other sections of the general community. With such high
rates of depression, undiagnosed mental disorders and
interpersonal problems in Pakistan, innovative treatment
modalities need to be developed. Programmes involving
community-based interventions through primary health
care workers (PHeW) and integrating mental health into
primary healthcare are the most promising-e.
Studies in Pakistan also show that about 40% of clients
of traditional healers suffer from mental illness23. Since
there are few specialized professionals, the community
turns to the available traditional healers. Involvement of
traditional healers in the care of the mentally ill is an
important mental health initiative in developing countries.
Professionals can give healers accurate information about
mental and behavioural disorders, encourage them to
function as referral agents, and discourage practices such
as starvation and punishments. For their part, profes-
sionals can come to understand the healers' skills in
dealing with psychosocial disorders 22 .
To reduce the incidence of suicide in young people
school-based interventions which include crisis manage-
ment, self-esteem enhancement, development of social
skills and healthy decision making are some of the
effective intervention strategies, as proposed in the
WHO Suicide Prevention Programme",
Government has an important role to play in terms of
the legal status of attempted suicide, which clearly reflects
the larger societal attitude and response to it. The broader
aim of suicide prevention has to include the legal status of
attempted suicide. The 'criminalization' of attempted
suicide has lead to stigma, avoidance of seeking help,
lack of involvement of the professionals and limitations in
developing innovative programmes of suicide prevention.
There is therefore an urgent need to change the law in
Pakistan.
The decriminalization of suicide and attempted suicide
will contribute to a change in the public attitude towards
Tropical Doctor April 2003, 33

this behaviour. Despite the fact the Islamic religion
strongly condemns suicide as an unforgivable sin, the
suicidal person is frequently seen not as a sinner, but as a
victim. This is especially true when suicide occurs as a
result of unbearable conditions such as poverty or
intolerable treatment of a woman by her spouse. The
suicidal behaviour is then seen as an understandable
reaction to traumatic events and pain.
There is a need for more and better information on
suicidal behaviour. Data collection at district, provincial
and national levels should be developed. The information
could be used for analytical epidemiological studies of
characteristics of high-risk groups and the changes in
those characteristics that take place over time. Pakistan
should be encouraged to report mortality data on suicide
to the WHO.
At a macro level, the issue of poverty alleviation needs
to be addressed and equitable, fair and just social policies
formulated. The high prevalence of depression in Pakistan
appears to be related to the high levels of social adversity
experienced by the population. Suicide prevention there-
fore poses a formidable challenge to governments, policy
makers, aid donors and mental professionals alike.
References
World Health Organization. Preventing Suicide: a Resource
for Primary Health Care Workers. WHO/MNH/MBD/OO.4.
Geneva: WHO, 2000
2 Social Policy and Development Center. Social Development in
Pakistan: Annual Review 2000. Karachi: Oxford University
Press, 2001
3 Khan MM, Reza H. The pattern of suicide in Pakistan.
Crises 2000;20:31-5
4 Masaryk T. Suicide and the Meaning of Civilisation.
University of Chicago Press, 1970
5 Morselli EA. Suicide: An Essay on Comparative Moral
Statistics. Appleton--Century, 1879
6 Durkheim E. Suicide. Free Press, 1951
7 Simpson ME, Conklin GH. Socio-economic development,
suicide and religion: A test of Durkheim's theory of religion
and suicide. Soc Forces 1989;67:945-64
8 Headley LA, ed. Suicide in Asia and the Near East. Berkley:
University of California Press, 1983
9 Chaleby KS. Issues in forensic psychiatry in Islamic
jurisprudence. Bull Am Acad Psych Law 1996;24: 117-24
10 Ashraf M. The problem of suicide in Karachi. Pak Armed
Forces Med J 1964;14: 156
II Ahmed SH, Zuberi H. Changing pattern of suicide and
parasuicide in Karachi. J Pak Med Assoc 1981;31:76--8
12 Human Rights Commission of Pakistan. The Dawn 6 Nov
2000
13 Lawyers for Human Rights and Legal Aid. The Dawn 6
March 2001
14 Sindh Police Report. The Dawn 13 September 2001
15 Bhutta ZA. Why has so little changed in maternal and child
health in South Asia? BMJ 2000;321:809-12
16 Husain N, Creed F, Tomenson B. Depression and social
stress in Pakistan. Psychol Med 2000;30:395-402
17 Mumford DB, Nazir M, Jilani F, Baig IY. Stress and
psychiatric disorder in the Hindu Kush: a community survey
of mountain villages in Chitral, Pakistan. Br J Psych
1996;168:299-307
18 Mumford DB, Saeed K, Ahmad I, Latif S, Mubbashar M.
Stress and psychiatric disorder in rural Punjab. A commu-
nity survey. Br J Psych 1997;170:473--8
19 Khan MM, Reza H. Gender differences in non-fatal suicidal
behaviour in Pakistan. Role of socio-cultural factors. Suicide
Life Threat Behav 1998;28:62-8
20 Naeem S. Vulnerability factors for depression in Pakistani
women. J Pak Med Assoc 1992;42:137-8
Tropical Doctor April 2003, 33
Reviews
21 Fikree F, Bhatti LI. Domestic violence and health of
Pakistani women. Int J Gynaecol Obstet 1999;65:195--201
22 The World Health Report 2001. Mental Health: New
Understanding, New Hope. Geneva: World Health Organiza-
tion, 2001
23 Saeed K, Gater R, Hussain A, Mubbashar M. The
prevalence, classification and treatment of mental disorders
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Psych Psych Epidemiol 2000;35:480-5
Urethral strictures: 'once a
stricture, always a stricture'
A Bazo LMS FRCS(Edin) K Rao MS FRACS
Leicester General Hospital, UK
Correspondence to: Alvaro Bazo, 17 Cardwell Court, Braithwell,
Rotherham 566 7AN, 5 Yorks, UK
E-mail: bazo@doctors.org.uk
TROPICAL DOCTOR, 2003, 33, 69-71
A urethral stricture is a narrowing of the normal calibre of
the urethra. Predominantly a male disease, the majority of
cases are of unknown aetiology. Common causes are
infections, such as gonococcal and non-specific urethritis,
balanitis xerotica obliterans (BXO), trauma and increas-
ingly iatrogenic.
Whatever the cause, there is a change in the lining of the
urethra to a columnar epithelium lacking the waterproof
property of the normal pseudo-stratified epithelium. This
leads to fibrosis and consequently more leakage of urine,
perpetuating the cycle. In addition, the involvement of the
ostia of para-urethral glands leads to the formation of
micro-abscesses hence contributing to the extension of the
stricture 1.
Treatment aim is to minimize the complications
(bladder outflow obstruction, retention, sepsis, watering
can perineum), associated with longstanding strictures,
and provide as long a stricture free period as possible.
Cure, although not impossible, is difficult to achieve.
The normal male urethra measures approximately
20 ern and comprises three parts: the prostatic urethra,
the membranous urethra and the penile urethra. The
aetiology and management of the stricture will vary
depending upon location. Prostatic urethral strictures
commonly occur after transurethral resection of the
prostate, membranous urethral strictures are most com-
monly after trauma, especially in pelvic fractures and
instrumentation, and infections. Penile urethral strictures
are common in BXO and as a result of instrumentation.
The traditional treatment of stricture was, up to the
development of the modern cystoscope, a blind proce-
dure, either by blind urethrotomy or dilatation. Great
skill was required to do this.
The development of endoscopic equipment, particularly
the Sachsse urethrotome-, which incorporates a cold knife
in a cystoscope, has meant that initial evaluation and
treatment is done visually. An 'optical' urethrotomy,
cutting the length of the stricture longitudinally at a 12 or
6 o'clock position, is therefore possible in a majority of
patients.
With urethrotomy and/or urethral dilatation, the best
results are those obtained when dealing with short < I em
69